Clostridioides Difficile Colitis Research Articles

The always evolving diagnosis and management of Clostridioides difficile colitis: What you need to know.

The diagnosis, pharmacologic management, and surgical options for Clostridioides difficile infection (CDI) are rapidly evolving, which presents a challenge for the busy surgeon to remain up to date on the latest clinical guidelines. This review provides an evidence-based practical guide for CDI management tailored to the needs of surgeons and surgical intensivists. Historically, the diagnosis of CDI relied on slow cell culture cytotoxicity neutralization assays, but now, the rapidly resulting nucleic acid amplification tests and enzyme immunoassays have become mainstream. In terms of antibiotic therapy, metronidazole and oral vancomycin were the main "workhorse" antibiotics in the early 2000s, but large randomized controlled trials have now demonstrated that fidaxomicin produces superior results. Regarding surgical intervention, total abdominal colectomy was once the only procedure of choice; however, diverting loop ileostomy with colonic lavage is emerging as a viable alternative. Finally, novel adjuncts such as fecal microbiota transplantation and targeted therapy against toxin B (bezlotoxumab) are playing an increasingly important role in the management of CDI.

Impact of Helicobacter pylori Eradication on Inflammatory Bowel Disease Onset and Disease Activity: To Eradicate or Not to Eradicate?

Helicobacter pylori infection has significant epidemiological relevance due to the carcinogenic nature of this bacterium, which is potentially associated with cancer. When detected, it should ideally be eradicated using a treatment that currently involves a combination of gastric acid suppressors and multiple antibiotics. However, this treatment raises questions regarding efficacy and safety profiles in patients with specific comorbidities, including inflammatory bowel diseases (IBD). Eradication therapy for H. pylori includes components associated with adverse gastrointestinal events, such as Clostridioides difficile colitis. This necessitates quantifying this risk through dedicated studies to determine whether this antimicrobial treatment could be significantly associated with IBD relapse or exacerbation of pre-existing IBD, as well as whether it could potentially lead to the de novo onset of IBD. Although the available evidence is reassuring about the safety of eradication therapy in patients with IBD, it is limited, and there are no specific recommendations for this particular situation in the leading international IBD and H. pylori guidelines. Therefore, studies need to evaluate the efficacy and safety profiles of the available antimicrobial regimens for H. pylori eradication in patients with IBD, both in clinical trial settings and in real-life studies.

Insoluble polysaccharides produced in plant cell cultures protect from Clostridioides difficile colitis

Clostridioides difficile infection (CDI) poses a significant health threat due to high recurrence rates. Antimicrobial agents are commonly used to manage CDI-related diarrhoea; however, by aggravating intestinal dysbiosis, antibiotics enable C. difficile spores germination and production of toxins, the main virulence factors. Therefore, the binding of exotoxins using adsorbents represents an attractive alternative medication for the prevention and treatment of relapses. In this study, we provided evidence that the natural insoluble polysaccharides, named ABR119, extracted by plant cell cultures, effectively trap C. difficile toxins. In our experiments, ABR119 exhibited no cytotoxicity in vitro and was safely administered in vivo. In the animal model of C. difficile-associated colitis, ABR119 (50 mg/kg body weight) significantly reduced the colonic myeloperoxidase activity and severity of inflammation, preventing body weight loss. These effects were not evident when we treated animals with wheat bran polysaccharides. We did not detect bacterial killing effects of ABR119 against C. difficile nor against bacterial species of the normal gut microbiota. Moreover, ABR119 did not interfere in vitro with the antimicrobial activities of most clinically used antibiotics. In summary, ABR119 holds promise for treating and preventing C. difficile colitis by trapping the bacterial toxins, warranting further studies to assess the ABR119 potential in human infections caused by C. difficile.

Hospitalization outcomes of patients with colorectal cancer (CRC) admitted with Clostridioides difficile colitis.

e15649 Background: Clostridioides difficile colitis poses a significant healthcare burden and is a leading cause of diarrheal disease. Emerging studies have suggested that certain C. difficile strains may potentially drive colonic tumorigenesis and C. difficile was more frequently isolated from colorectal cancerous lesions compared to healthy tissue. In addition, cancer patients are more likely to receive antibiotics. These factors place CRC patients at a high risk of acquiring C. difficile infection. This national inpatient sample (NIS) study aims to study the hospitalization outcomes of patients with CRC admitted with C. difficile colitis. Methods: A retrospective analysis of the NIS database from 2016 to 2020 was conducted using International Classification of Diseases (ICD-10) codes to identify hospitalizations with C. difficile colitis. STATA version SE18.0 was used for statistical analysis. We used multivariate regression analysis to calculate the effect on mortality, length of stay, ileus and cost of hospitalization of colorectal cancer along with other variables as listed below. Results: There were 246685 hospitalizations with a primary diagnosis of C. difficile colitis. Among these, 2250 patients had a secondary diagnosis of colorectal cancer. Multivariate logistic regression showed that CRC was associated with increased mortality with odds ratio (OR) of 2.24 [95% confidence interval (CI) 1.13-4.44, p-value = 0.02], ileus (OR of 1.99, 95% CI 1.16-3.41, p-value = 0.01) and cost of hospitalization (10,585$ higher than patients without CRC, p-value = 0.001). CRC was not associated with increased length of stay (OR of 1.31, 95% CI 0.63-1.99). The effect of other pertinent variables is summarized in Table 1. Conclusions: Among the analyzed variables, we observed that colorectal cancer was associated with increased mortality, ileus and total cost of hospitalization in patients admitted with C. difficile colitis. Limitations of this study include failure of the multivariate model to account for other possible variables, coding errors and risk of bias due to the retrospective nature of data. [Table: see text]

Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study

BackgroundAntibiotics with extended anaerobic coverage are commonly used to treat aspiration pneumonia, which is not recommended by current guidelines. Research questionIn patients admitted to hospital for community-acquired aspiration pneumonia, is there a difference between antibiotic therapy with limited anaerobic coverage (LAC) versus antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis? MethodsWe conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada from January 1, 2015 to January 1, 2022. Patients were included if the physician diagnosed the patient with aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy within 48 hours of admission. Patients were then categorized into LAC group if they received ceftriaxone, cefotaxime or levofloxacin. Patients were in the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause mortality in hospital. Secondary outcomes included incident C. difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors. ResultsThere were 2,683 and 1,316 patients in the LAC and EAC group respectively. In hospital, 814 (30.3%) and 422 (32.1%) patients in the LAC and EAC group died respectively. C. difficile colitis occurred in 5 or less (≤0.2%) and 11 to 15 (0.8% to 1.1%) patients in the LAC and EAC group respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI 0.3% to 1.7%) for C. difficile colitis. InterpretationExtended anaerobic coverage is likely unnecessary in aspiration pneumonia because it is associated with no additional mortality benefit, only an increased risk of C. difficile colitis.

A comprehensive assessment of the prolonged febrile neutropenia evaluation in pediatric oncology patients.

Pediatric oncology patients with prolonged (≥96hours) febrile neutropenia (absolute neutrophil count<500/μL) often undergo an evaluation for invasive fungal disease (IFD) and other infections. Current literature suggests that beta-D-glucan (BDG), galactomannan, bronchoalveolar lavage (BAL), and computed tomography (CT) scans (sinus, chest, and abdomen/pelvis) may help determine a diagnosis in this population. In a retrospective cohort study of all cancer/stem cell transplant patients (diagnosed 2005-2019) from one pediatric hospital, all episodes with prolonged febrile neutropenia or IFD evaluations (defined as sending a fungal biomarker or performing a CT scan to assess for infection) were identified. In total, 503 episodes met inclusion criteria and 64% underwent IFD evaluations. In total, 36.4% of episodes documented an infection after initiation of prolonged febrile evaluation, most commonly Clostridioides difficile colitis (6.4%) followed by a true bacterial bloodstream infection (BSI) (5.2%), proven/probable IFD (4.8%), and positive respiratory pathogen panel (3.6%). There was no difference in sinus CTs showing sinusitis (74%vs 63%, p=0.46), whereas 32% of abdomen/pelvis CTs led to a non-IFD diagnosis, and 25% of chest CTs showed possible pneumonia. On chest CT, the positive predictive value (PPV) for IFD was 19% for nodules and 14% for tree and bud lesions. BDG had a PPV of 25% for IFD and GM 50%. BAL diagnosed IFD once and pneumocystis jirovecii pneumonia twice. Chest CTs and abdomen/pelvis CTs provide clinically relevant information during the prolonged febrile neutropenia evaluation, whereas BDG, galactomannan, BAL, and sinus CTs have less certain utility.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan.

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy. CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria. Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses. Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results. The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

1467. Effects Of Oral Antibiotic Prophylaxis For Surgical Site Infections In Colorectal Surgery: Insights From Real World Data

Abstract Background Surgical site infection (SSI) after colorectal surgery is a significant burden on healthcare costs and patient quality of life. Preventive strategies are very important to working on this problem. In a multicenter randomized controlled trial (RCT) published in Annals of Surgery(2016;263:1085-1091), we reported the efficacy of oral antimicrobial prophylaxis in preventing SSI before colorectal surgery. Since the end of the RCT in 2012, we have applied this prophylaxis in our clinical practice and have experienced a large number of cases. Here, we report the incidence of SSIs when this prophylactic measure is applied in real-world clinical practice. Methods We retrospectively evaluated the incidence of SSI in 1192 patients who underwent elective laparoscopic colorectal resection for colorectal tumors between January 2013 and June 2022. We excluded 24 patients who were unable to receive oral prophylaxis. Antimicrobial prophylaxis consisted of oral kanamycin (1 g) and metronidazole (750 mg) twice on the day before surgery and intravenous cefmetazole (1 g) just before and every 3 hours during surgery. The diagnosis of SSI follows the CDC/NHSN definition. Results Our study included 647 males and 545 females, with a mean age of 69.3 years (IQR 63-77) and BMI of 22.6 kg/m2 (IQR 20.2-24.7). The incidence of SSI in all surgical cases was 61/1192 (5.1%; 95% CI 4.0-6.5). The incidence of SSIs in colon surgery was 16/769 (2.1%; 95% CI 1.3-3.4), and in rectal surgery, 45/400 (11.3%; 95% CI 8.5-14.7). The incidence of Clostridioides difficile colitis, which is regarded as a side effect of oral antimicrobial agents, was low at 6/1192 cases (0.5%; 05%CI 0.2-1.1). In our previous RCT, the incidence of SSI was 21/289 (7.26%) in patients treated with oral antibiotics. In a subanalysis of this trial published in the International Journal of Colorectal Disease(2016;31:1775-1784), the incidence of SSI was 9/188 (4.8%) in colon surgery and 13/103 (13%) in rectal surgery. The incidence of SSIs in the present data was similar to or lower than the incidence of SSIs in well-conditioned patients selected in the RCT. Conclusion Our results suggest that preoperative oral antibiotic prophylaxis in colorectal surgery is an effective method to reduce SSIs in a wide variety of patients in real-world clinical practice. Disclosures All Authors: No reported disclosures

Zmena epidemiologického charakteru klostrídiovej kolitídy – rastúci počet komunitných foriem a infekcií u detí

Clostridioides difficile colitis has long been considered an infection associated with hospitalization and concomitant antibiotic treatment. However, the increasing number of community cases in recent years has led to a reassessment of the traditional understanding of its epidemiological characteristics. In addition, community-associated forms have been reported many times in children, young adults, or people without comorbidities and with a negative history of antibiotic use in the pre-disease period. These groups have traditionally been considered low risk for the development of the infection. Thus, many studies have naturally investigated the impact of asymptomatic Clostridioides difficile carriers, including neonates and infants, on the transmission of the causative agent in the community. The prevalence of this bacterium in animals, in food and in the environmental setting has also been the subject of research. The goal was to elucidate the role of these factors in the spread of the agent in community settings. In this article, we summarize the current knowledge on confirmed and potential risk factors for community-acquired Clostridioides difficile infection, together with the results of studies examining patient characteristics. We also provide information on the issue of Clostridioides difficile infection in the paediatric population, which is closely intertwined with the community-acquired form of the infection. Keywords asymptomatic carrier state, Clostridioides difficile, epidemiology, community-acquired infections

Successful Treatment of Refractory Fulminant Clostridioides Difficile Colitis after Ileocolostomy Reversal Using Faecal Microbiota Transplant

Clostridioides difficile (C.diff) colitis accounts for significant morbidity, mortality and inpatient bed days. Prevalence of C.diff associated diarrhoea (CDAD) in general surgical patients is high. Faecal Microbiota Transplant (FMT) is a recognised treatment for recurrent CDAD, but there is minimal evidence for its use in primary CDAD.

Perspectives on nonprescription antibiotic use among Hispanic patients in the Houston metroplex: A qualitative study

Background: Nonprescription antibiotic use includes taking an antibiotic without medical guidance (eg, leftover antibiotics, antibiotics from friends or relatives, or antibiotics purchased without a prescription). Nonprescription use contributes to antimicrobial resistance, adverse drug reactions, interactions, and superinfections such as Clostridioides difficile colitis. Qualitative studies exploring perspectives regarding nonprescription use among Hispanic patients are lacking. We used the Kilbourne Framework for Advancing Health Disparities Research to identify factors influencing Hispanic patients’ nonprescription use and to organize our findings. Methods: Our study includes Hispanic primary-care clinic patients with different types of health coverage in the Houston metroplex who endorsed nonprescription use in a previous quantitative survey. Semistructured interviews explored the factors promoting nonprescription use in Hispanic adults. Interviews were conducted remotely, in English or Spanish, between May 2020 and October 2021. We used inductive coding and thematic analysis to identify the factors and motives for nonprescription use. Results: Of the 35 Hispanic participants surveyed, 69% were female and between the ages of 27 and 66. All participants had some form of healthcare coverage (eg, Medicare or private insurance, Medicaid, or the county financial assistance program). Participants reported obtaining antibiotics from their own leftover prescriptions and through trusted persons (eg, herbalists, pharmacists, friends/relatives, and others), buying them under the counter in US markets, and purchasing them without a prescription outside the United States. Thematic analysis revealed the factors contributing to nonprescription use (Fig. 1). Themes included beliefs that the ‘doctor visit was unnecessary,’ ‘limited direct access to healthcare’ in the United States (due to limited insurance coverage, high costs of the doctor’s visits and medications, and long clinic wait times), ‘more open indirect access to healthcare’ abroad and under the counter in the United States, and communication difficulties (eg, language barriers with clinicians, perceived staff rudeness, and gaps in health literacy). Figure 2 shows representative quotes across thematic domains. Participants expressed having confidence in medical recommendations from pharmacists and trusted community members in their social networks. Conclusions: Antibiotic stewardship interventions that include pharmacist-driven patient education regarding appropriate antibiotic use may decrease nonprescription antibiotic use in Hispanic communities. Additionally, improving access to care while addressing communication barriers and cultural competency in clinics may improve primary care delivery and reduce potentially unsafe antibiotic use.Disclosure: None

Coexisting cytomegalovirus colitis in an immunocompetent patient with Clostridioides difficile colitis: A case report

Clostridioides difficile (C. difficile) colitis is one of the most common infections in hospitalized patients, characterized by fever and diarrhea. It usually improves after appropriate antibiotic treatment; if not, comorbidities should be considered. Cytomegalovirus (CMV) colitis is a possible co-existing diagnosis in patients with C. difficile infection with poor treatment response. However, compared with immunocompromised patients, CMV colitis in immunocompetent patients is not well studied. We present an unusual case of co-existing CMV colitis in an immunocompetent patient with C. difficile infection. An 80-year-old female patient was referred to the infectious disease department due to diarrhea, abdominal discomfort, and fever for 1 wk during her hospitalization for surgery. C. difficile toxin B polymerase chain reaction on stool samples was positive. After C. difficile infection was diagnosed, oral vancomycin treatment was administered. Her symptoms including diarrhea, fever and abdominal discomfort improved for ten days. Unfortunately, the symptoms worsened again with bloody diarrhea and fever. Therefore, a sigmoidoscopy was performed for evaluation, showing a longitudinal ulcer on the sigmoid colon. Endoscopic biopsy confirmed CMV colitis, and the clinical symptoms improved after using ganciclovir. Co-existing CMV colitis should be considered in patients with aggravated C. difficile infection on appropriate treatment, even in immunocompetent hosts.

Do Antibiotics Prevent Infectious Complications in Critically Injured Patients With Blunt Nonoperative Midfacial Trauma?

While recent literature suggests antibiotics are not needed in patients with nonoperative facial fractures involving sinuses, the existing studies do not focus on critically injured patients who are known to be at higher risk for sinusitis and ventilator-associated pneumonia, which could be exacerbated by facial fractures. The purpose of this study was to determine if antibiotics reduce the rate of infectious complications in critically injured patients who have blunt midfacial trauma treated nonoperatively. The authors conducted a retrospective cohort study consisting of patients admitted to the trauma intensive care unit who sustained blunt midfacial injuries managed nonoperatively at an urban Level 1 trauma center from August 13th, 2012, to July 30th, 2020. Adults who were critically injured on admission and sustained a midfacial fracture involving a sinus were included in the study. Patients who underwent operative repair of any facial fracture were excluded. The predictor variable was the use of antibiotics. The primary outcome variable was the development of infectious complications, such as sinusitis, soft tissue infection, or any type of pneumonia, including ventilator-associated pneumonia (VAP). The data were analyzed using Wilcoxon rank sum tests, Fisher exact tests, and multivariable logistic regression as appropriate for analysis type with significance level set at <0.05. The study included 307 patients, with a mean age of 40.6years. Men accounted for 85.0% of the study population. Antibiotics were administered to 229 (74.6%) of the study population. Complications developed in 13.6% of the patients, which included sinusitis (0.3%), VAP (7.5%), and other types of pneumonia (5.9%). Clostridioides difficile colitis developed in 2 patients (0.6%). Antibiotics were not associated with a decrease in infectious complications in either the unadjusted analysis (13.1% in antibiotic group, 15.4% in no antibiotic group, RR=0.85 [95% confidence interval=0.5 to 1.6], P=.7) or the adjusted analysis (odds ratio 0.74 [0.34 to 1.62]). Even in this critically injured patient population thought to be at elevated risk for infectious complications from their midfacial fractures, the rates of infectious complications in those who received antibiotics and those who did not were no different. These results suggest that consideration of more judicious use of antibiotics is warranted in critically ill patients with nonoperative midface fractures.

Which microbiota-based therapies have proven to be effective today?

There is increasing interest in the microbiota (this includes bacteria, fungi and viruses) and microbiota-based therapies. The relationship between changes in the composition of the intestinal microbiota and the pathogenesis of various diseases is of specific interest. In particular, the possibilities offered by targeted manipulation of the microbiota composition as specific treatment approaches look promising. This review article summarizes the current data on microbiota-based therapies as well as the evidence-based treatment options applicable for certain diseases. Current data on the clinical effectiveness of microbiota-based therapies varies greatly between different diseases. While certain therapies proved successful in the treatment of some diseases, the data is still insufficient on their effectiveness in other diseases. So far, the most successful treatment in this context is fecal microbiota transplantation with asuccess rate of 80-90% for the treatment of Clostridioides difficile colitis. The correction of dysbioses of the intestinal microbiota could provide new possibilities for the treatment of diseases. However, due to the lack of acausal-functional understanding and the mainly descriptive knowledge to date, applications are still limited. The current clinical studies addressing the changes and the importance of intestinal microbiota could lead to new therapeutic options in the treatment of diverse diseases in the future.

Using a 29-mRNA Host Response Classifier To Detect Bacterial Coinfections and Predict Outcomes in COVID-19 Patients Presenting to the Emergency Department.

Clinicians in the emergency department (ED) face challenges in concurrently assessing patients with suspected COVID-19 infection, detecting bacterial coinfection, and determining illness severity since current practices require separate workflows. Here, we explore the accuracy of the IMX-BVN-3/IMX-SEV-3 29 mRNA host response classifiers in simultaneously detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and bacterial coinfections and predicting clinical severity of COVID-19. A total of 161 patients with PCR-confirmed COVID-19 (52.2% female; median age, 50.0 years; 51% hospitalized; 5.6% deaths) were enrolled at the Stanford Hospital ED. RNA was extracted (2.5 mL whole blood in PAXgene blood RNA), and 29 host mRNAs in response to the infection were quantified using Nanostring nCounter. The IMX-BVN-3 classifier identified SARS-CoV-2 infection in 151 patients with a sensitivity of 93.8%. Six of 10 patients undetected by the classifier had positive COVID tests more than 9 days prior to enrollment, and the remaining patients oscillated between positive and negative results in subsequent tests. The classifier also predicted that 6 (3.7%) patients had a bacterial coinfection. Clinical adjudication confirmed that 5/6 (83.3%) of the patients had bacterial infections, i.e., Clostridioides difficile colitis (n = 1), urinary tract infection (n = 1), and clinically diagnosed bacterial infections (n = 3), for a specificity of 99.4%. Two of 101 (2.8%) patients in the IMX-SEV-3 "Low" severity classification and 7/60 (11.7%) in the "Moderate" severity classification died within 30 days of enrollment. IMX-BVN-3/IMX-SEV-3 classifiers accurately identified patients with COVID-19 and bacterial coinfections and predicted patients' risk of death. A point-of-care version of these classifiers, under development, could improve ED patient management, including more accurate treatment decisions and optimized resource utilization. IMPORTANCE We assay the utility of the single-test IMX-BVN-3/IMX-SEV-3 classifiers that require just 2.5 mL of patient blood in concurrently detecting viral and bacterial infections as well as predicting the severity and 30-day outcome from the infection. A point-of-care device, in development, will circumvent the need for blood culturing and drastically reduce the time needed to detect an infection. This will negate the need for empirical use of broad-spectrum antibiotics and allow for antibiotic use stewardship. Additionally, accurate classification of the severity of infection and the prediction of 30-day severe outcomes will allow for appropriate allocation of hospital resources.

S865 Impact of Inflammatory Bowel Disease in Colonic Resection for Those Hospitalized With Clostridioides difficile Colitis: Insights From the National Inpatient Sample

Introduction: Clostridioides difficile ( C. diff) is a common nosocomial infection with symptoms that range from a mild diarrheal illness to severe, life-threatening colitis. While there is sufficient data demonstrating risk factors, an understanding of factors for developing more severe disease is lacking. Previous literature has shown increased mortality for patients with inflammatory bowel disease (IBD) who become infected with c. difficile, however, a connection between IBD and need for colonic resection has not been established. Methods: This is a retrospective cohort study using the 2019 National Inpatient Sample (NIS). Inclusion criteria were a principal diagnosis of Clostridioides difficile colitis and age >18. The patients were divided into two groups: those with IBD and those without IBD. IBD was further subdivided into those with ulcerative colitis (UC) and those with Crohn's disease (CD). The primary outcome is rate of colonic resection. Secondary outcomes are: 1) mortality 2) rate of colonoscopy 3) length of stay 4) total hospital charges. Confounders were adjusted for using multivariate regression analysis with the following confounders: sex, income, race, insurance, Charlson comorbidity index, hospital bedsize, location, teaching status, and region. Results: 76,324 Patients were included in the study, 4.1% with IBD. Both groups predominantly consisted of Caucasian females treated at large, urban teaching hospitals in the Southern United States. 0.22% of the total population studied underwent resection. Compared to the rate of resection in patients without IBD, those with IBD had a 180% increase in odds of colonic resection when compared to patients without IBD while adjusting for confounders. This difference was most notable in the CD subgroup (OR of 4.41). Patients with IBD were also more likely to undergo colonoscopy (OR 3.4) and had hospital charges on average $6,799 more than those without IBD. (Figure) Conclusion: Those with IBD face an even higher burden of disease than those diagnosed with C. diff without IBD. Both forms of IBD increase the likelihood of the adverse event of colonic resection as a consequence of infection of C. diff while hospitalized, with CD patients having stronger odds of this outcome compared to those diagnosed with UC. With such a strong increase of unfavorable outcomes amongst patients diagnosed with IBD, hospitals should consider implementing stronger measures to prevent nosocomial C. diff amongst those admitted with IBD.Figure 1.: Graphical representation of nonobese versus obese patients hospitalized for Clostridioides difficile who underwent colonic resection during hospitalization. UC = ulcerative colitis; CD = Crohn's Disease; IBD = Inflammatory Bowel Disease

Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients.

Prolonged antibiotics are associated with toxicity, selection for resistant organisms, and secondary infections such as Clostridioides difficile colitis. Emerging clinical data suggest that short courses of antibiotics can be used for common bacterial infections among immune competent patients, but for many randomized controlled trials (RCTs), immunocompromised patients, including solid organ transplant recipients (SOTRs), have been excluded. Peer-reviewed publications were identified through PubMed and Embase searches. We review data examining shorter antibiotic courses among immunocompetent and immunocompromised patients and the rationale for use of short antibiotic courses in SOTRs. There are known harms associated with antibiotics and, when studied, existing data do not demonstrate harm associated with shorter courses of antibiotics among SOTRs. Furthermore, several RCTs did include some immune compromised patients and found shorter therapy to result in similar clinical efficacy with diminished adverse effects. Shorter antibiotic durations should be considered in SOTRs, and questions of antibiotic duration among SOTRs should be prioritized for study in clinical trials.

Concurrent and Subsequent Co-Infections of Clostridioides difficile Colitis in the Era of Gut Microbiota and Expanding Treatment Options.

We narratively reviewed the physiopathology, epidemiology, and management of co-infections in Clostridioides difficile colitis (CDI) by searching the following keywords in Embase, MedLine, and PubMed: “Clostridium/Clostridioides difficile”, “co-infection”, “blood-stream infection” (BSI), “fungemia”, “Candida”, “Cytomegalovirus”, “probiotics”, “microbial translocation” (MT). Bacterial BSIs (mainly by Enterobacteriaceae and Enterococcus) and fungemia (mainly by Candida albicans) may occur in up to 20% and 9% of CDI, increasing mortality and length of hospitalization. Up to 68% of the isolates are multi-drug-resistant bacteria. A pivotal role is played by gut dysbiosis, intestinal barrier leakage, and MT. Specific risk factors are represented by CDI-inducing broad-spectrum antibiotics, oral vancomycin use, and CDI severity. Probiotics administration (mainly Saccharomyces and Lactobacillus) during moderate/severe CDI may favor probiotics superinfection. Other co-infections (such as Cytomegalovirus or protozoa) can complicate limited and specific cases. There is mounting evidence that fidaxomicin, bezlotoxumab, and fecal microbiota transplantation can significantly reduce the rate of co-infections compared to historical therapies by interrupting the vicious circle between CDI, treatments, and MT. Bacterial BSIs and candidemia represent the most common co-infections in CDI. Physicians should be aware of this complication to promptly diagnose and treat it and enforce preventive strategies that include a more comprehensive consideration of newer treatment options.

An Overview of Healthcare Associated Infections and Their Detection Methods Caused by Pathogen Bacteria in Romania and Europe

Healthcare-associated infections can occur in different care units and can affect both patients and healthcare professionals. Bacteria represent the most common cause of nosocomial infections and, due to the excessive and irrational use of antibiotics, resistant organisms have appeared. The most important healthcare-associated infections are central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site, soft tissue infections, ventilator-associated pneumonia, hospital acquired pneumonia, and Clostridioides difficile colitis. In Europe, some hospitalized patients develop nosocomial infections that lead to increased costs and prolonged hospitalizations. Healthcare-associated infection prevalence in developed countries is lower than in low-income and middle-income countries such as Romania, an Eastern European country, where several factors contribute to the occurrence of many nosocomial infections, but official data show a low reporting rate. For the rapid identification of bacteria that can cause these infections, fast, sensitive, and specific methods are needed, and they should be cost-effective. Therefore, this review focuses on the current situation regarding healthcare-associated infections in Europe and Romania, with discussions regarding the causes and possible solutions. As a possible weapon in the fight against the healthcare-associated infections, the diagnosis methods and tests used to determine the bacteria involved in healthcare-associated infections are evaluated.

Infectious complications in acute graft‐versus‐host disease after liver transplantation

Graft-versus-hostdisease (GVHD) following liver transplantation (LT) is rare but can lead tosignificant mortality. The leading cause of death following GVHD diagnosis isinfectious complications. However, there is a lack of clear descriptions concerning infection and antimicrobial management patterns. Our study aims toprovide the focused details of all infectious complications of acute GVHDfollowing LT. We retrospectively reviewed all adult LT recipients with acute GVHD at Mayo Clinic's Transplant Centers from January 1, 2010, to December 31, 2021. Detailed characteristics of infection in each case were described. Among 4,585 LTs performed during this period, 12 (0.3%) patients developed acuteGVHD. The median time from transplantation to GVHD diagnosis was 49.0 days [IQR 31.5-99.0]. Ten (83.3%) patients developed severe infections leading tomortality. The most common cause of infection was nosocomial bacteremia fromenteric bacteria such as vancomycin-resistant enterococci and gram-negative bacilli. Other infections included breakthrough invasive fungal infections,cytomegalovirus (CMV) reactivation, and Clostridioides difficile colitis. Antimicrobial prophylaxis strategies in most cases were based on the degree of neutropenia-these include levofloxacin for bacterial prophylaxis, nebulized pentamidine for Pneumocystis jiroveci pneumonia prophylaxis, posaconazole for invasive fungal prophylaxis, and valganciclovir based on CMVstatus. All GVHD patients with severe infections succumbed to thesecomplications. Ourstudy reiterates that despite prophylaxis, infectious complications in GVHDfollowing LT are common and lead to exceptionally high mortality. Individualizedantimicrobial treatment, prophylaxis and monitoring strategies remain a criticalcomponent of GVHD management. Further study to optimize these practices isrequired.